Falls STILL (There's lots to say on this)

I could have written one very long blog post on falls, but I wasn't particularly interested in overwhelming you with all of the information rather I was interested in providing short bites about falls that can be processed each week.  

I was gonna take a break from falls but can't remember what I was going to talk about so we'll keep going on falls anyway. 

Today we're going to focus on falling out the window.  Another story that's stuck with me.  The woman suffered from a diagnosis of dementia.  She resided on a locked second floor unit of a local nursing home.  She had decided that she needed to go to the grocery store.  She couldn't get off the unit through the door, so she went to her room to attempt to open the window.  The window opened so she climbed out the window, falling to the bushes below. 

Thankfully she only suffered a broken arm. 

When the state investigated what happened they found that the unit was in disrepair.  The little device that stops the window from opening at 4 inches was missing.  It was found that the staff knew that the window opened wider than four inches and failed to repair the window to prevent the client from leaving via the window and harming herself. 

In this case the staff was very lucky that the client did not hurt herself more severely than a broken arm, but it is clear that they failed to provide a safe environment.  

This would have been a difficult case, except for the reporting to the state and the state doing a thorough investigation.  Because they did the investigation it was found that the cause of the fall was the window being in disrepair, and that the staff knew the window was in disrepair, yet failed to do anything about it. Further the nursing staff failed to report up the chain of command that the maintenance staff failed to fix the window. 

After the state came in the window was fixed the next day but the damage was done. 

This is an uncomplicated fall out the window.  Usually they are more complicated than that and a nurse is needed to investigate the whys of a fall out the window.  Was there psychosis due to medication errors prior to the fall, or was there suicidal ideations (the expression of the desire to commit suicide and a concrete plan) without close and appropriate medical supervision before the fall. What was the outcome?  Nursing helps with all of these.